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Hospital Play #5 – Standardizing Best Practices: Identifying and Reducing Variability in Surgical Procedures

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July 26, 2018

Many hospitals are taking on standardization initiatives to streamline processes and reduce costs. We’ve found that intra-operative processes of the OR are often the last areas many hospitals tackle – even though it is the largest revenue center!

Variability in surgical procedures is a given and some is inherent to clinical practice – a surgeon’s handedness requires different setup, a bariatric patient requires different tools. Yet the codification of where this variability exists and the opportunity to identify and share best practices is a science just beginning to emerge. Mapping out intra-operative activity creates a dataset that improves hospital financial, operational and clinical performance by cutting OR setup and intra-operative time, reducing anesthesia time for patients and improving performance quality from a confident team..


What are the critical enablers of procedural mapping and analysis projects?


The ability to perform side-by-side analysis

Creating visual differences between surgical procedures is essential for surgical process mapping and optimization projects. Specifically the ability to detail major steps and sub steps of a given procedure is critical to identifying variability. The Royal Orthopedic Hospital NHS Trust [i] shows the value of surgical process mapping. Here, the intraoperative processes of the carpal tunnel release were carefully mapped then re-engineered. A visual map of the restructured process was displayed in the OR. After a two week learning period, eight more procedures were run, with mapping and time stamping conducted again. This resulted in a mean reduction of 20 percent in total operating time.

The ability to capture role-specific sub-steps for a surgeon, resident, anesthesiologist, surgical tech or circulator is easy with ExplORer Surgical. Our software makes it possible to review procedures for different surgeons side-by-side in detail and quickly identify variances overall and by role.


The ability to collect procedural data

Collecting procedural data is not only time consuming, but also  negatively impacts quality, cost of procedural evaluation and redesign efforts. At the University Medical Center Leipzig [iii], the intraoperative processes of 105 cataract procedures, as performed by three surgeons  were mapped and analyzed. Researchers recorded who was performing a given action, what was being done during that activity, the material whereby it was done, where anatomically it was done and when it was done (i.e., its duration). The researchers concluded “that detailed profiles could be gathered with the help of Surgical Process Modeling” to “provide… an exact, validated and objective decision base for the support of surgical teaching in the realm of evidence-based eye surgery” and that having “a profound exchange of experience [between surgeon and residents] would be very useful.”

Imagine if the cataract team had been equipped with an organic application like ExplORer which could enable education, rapid preparation  and real-time reference points during procedures. With ExplORer, surgical teams can efficiently collect data by step, track task completion by specific roles, document errors and collect evaluative assessments--all of which can be done in or outside the OR. Teams can use this data to compare and contrast procedures and enable post-redesign training.


Figure 2. ExplORer tablet in use intraoperatively by a scrub,  records rich data.


The ability to manage best practice procedures

Having a system to manage  best practice procedures ensures your team of their sustainability and impact. Procedural redesign efforts must be built to share best practice approaches with surgical teams and enable ongoing evaluation. At the University of Chicago and NorthShore University Health System,  our CMO and co-founder, Dr. Alex Langerman [ii], examined variations in performance of the pancreaticoduodenectomy. The technical steps taken by five surgeons during this procedure were compared to a popular surgeon textbooks outline and to nursing and anesthesia textbooks.  Major variations were identified, including the order of operations, the type of resection tool used and the technique for division of the pancreas. Furthermore, “…they found 21 surgical step data points that differed among the 5 surgeons”.

This represents a strong need for further analysis of the impact of variability in teaching methods at different stages. Individualized data enabled residents to select the operative method most appropriate for their skill level. With ExplORer, surgery departments can share best practices and iteratively A/B test procedures, ensuring surgical team performance is uniform across a health system.  


The OR is one of the last areas for hospitals to drive down costs. Increased efficiencies and substantial gains are possible. Research shows significant headway can be made through the collection and study of intra-operative processes and the analysis of variability, especially in reduction of procedural durations, improvement of education, increased standardization and identification of the most appropriate surgical protocol. With an intra-operative technology like ExplORer, performance improvement initiatives can happen at greater scale with ease and collaboration across surgical teams.


If you are working to improve the performance of your surgical teams, contact us at We’d like to speak with you and see if we can help accelerate your progress.


[i] Casaletto JA, Rajaratnam V. Surgical process re-engineering: carpal tunnel decompression--a model. Hand Surg. 2004;9(1):19-27.

[ii]Davidson SJ, Rojnica M, Matthews JB, Langerman AJ. Variation and Acquisition of Complex Techniques: Pancreaticoduodenectomy. Surg Innov. 2016;23(6):586-592.

[iii] Neumeister, Michael W. “Welcome to the Department of Surgery”. SIU School of Medicine Surgery.



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